Documentation: A Necessary and Useful Tool

Reasons to Document

Documentation is often felt to be an inconvenient, pointless task by many professionals.  It is a required task in working with client populations, such as residents of nursing facilities (NFs) and assisted living facilities (ALFs), but many staff can resent the time it takes to document resident care.  Often, staff list various reasons for not documenting,which may include:

  • "It takes time away from my work with clients."
  • "It’s boring and redundant."
  • "I don’t think anyone looks at it anyway."
  • "I’m doing my job and everyone knows it.  They don’t need a note to see that."

Although most professionals can relate to the frustrations staff have with documenting, documentation is important to complete regularly for a number of reasons.  Accurate documentation allows for continuity of care and provides proof of interventions and care.  Many professional organizations, such as the National Association of Social Workers (NASW) and the American Nurses Association (ANA), recognize the importance of documentation and include direction in their code of ethics and/or standards of practice. The licensing agencies that oversee long term care facilities also provide some direction for documenting a resident’s abilities and the care provided to the resident. In nursing facilities, what is commonly called a Care Plan addresses the resident’s needs and how those needs will be met. The Virginia Department of Health-Office of Licensing and Certification licenses nursing facilities. In assisted living facilities, what is known as an Individualized Service Plan (ISP) reviews how goals will be met based on the needs of the resident. Documentation that follows up on the Care Plan or ISP shows if a plan’s implementation is successful and needs to be continued as written.  It will also show if a plan or a portion of the plan is unsuccessful and should be changed to more appropriately meet the needs of a resident.  The Virginia Department of Social Services licenses assisted living facilities. Although documentation mandates differ depending on whether a facility is a NF or an ALF, the underlying reason for documentation in both types of facilities is to ensure that every resident receives care appropriate to his or her needs and abilities.

Despite the fact that documentation can often feel tedious and redundant, supervisors, licensing agencies as well as other healthcare oversight agencies, and facility staff review documentation for knowledge about a resident's well-being and care.  Documentation can provide insight into a resident’s change in condition or techniques that have previously worked in the past to address resident concerns. Accurate and timely documentation can alert staff to resident needs that recur or are new to the resident. Documentation can allow for better communication when staff provide referrals to services, whether the services are internal or external services.  Documentation also shows the facility staff’s ability to follow through and provide appropriate care to each of the residents under the facility’s care.

A Note Regarding Confidentiality

Residents are legally entitled to confidentiality of their records. Federal guidelines to confidentiality and privacy of records can be found in the Health Insurance Portability and Accountability Act (HIPAA). Licensing agencies address the concern of confidentiality in their regulations or standards. The Ombudsman Program, which reviews residents’ rights practices in facilities, also can address concerns regarding confidentiality of records. Facility staff should be aware of the confidentiality protections to which residents are entitled and be careful to protect that confidentiality in storing and reviewing records. In addition, it is important to know who can see the records. Except in certain situations, the resident and his or her representative has the right to view and receive a copy of his or her records. Staff of agencies that are considered healthcare oversight agencies, such as licensing agencies and the Ombudsman Program, are also able to view and receive copies of resident records.

Some Common Documentation Pitfalls

  • Abbreviations
    The use of abbreviations is a common practice when writing notes about residents. Abbreviations are one way of increasing speed in documenting. However, it is importantfor staff to realize that abbreviations can be confusing. Some facilities may have accepted abbreviations to use and others may not. When using abbreviations, facility staff should follow their facility’s policy on abbreviation use and use facility accepted abbreviations. If the facility does not have accepted abbreviations or a policy, a good guideline to follow is to assume that the person reading the note does not know the abbreviation. Staff can easily address this by writing out the abbreviation initially then using the abbreviation in the remainder of the document. For instance, staff could write "Discussed pending discharge (dx) with resident and her family. Family requested further information on Medicare dx information. Writer will obtain requested information on dx and provide to resident, who has agreed to give it to her family on their next visit to facility."

  • Slang
    Although many people use slang during the course of a normal conversation, slang should be avoided in documentation. Slang is often regional, with meanings varying in different places. Some slang is only used in certain areas. For instance, the phrase "ret up the room" might mean something to an individual who has visited or lived in Central Pennsylvania, but may mean nothing to everyone else. Instead, if the phrase "clean the room" is used, more individuals would understand the meaning.

  • Spelling and Grammar
    It is certainly a possibility that busy staff might misspell words or have grammatical errors while documenting. However, misspellings and grammar mistakes can be just asconfusing to the reader as the use of slang and abbreviations. Remember that some words spelled differently can have different meanings, just as the use of grammar can say something differently than the writer intended. If a facility uses computers to document, staff can consistently use spell check if available to help address spelling errors.Although spell check is not available to staff who document by hand, re-reading a document often helps staff catch grammatical and spelling errors quickly no matter what form documenting takes. Clear use of pronouns is also important, as saying “he” or “she” throughout a document can mean a variety of different people, including residents, staff, or family members. Readers may be confused as to which “he” or “she” a writer is referring to if that is not made clear.

  • Objective Documentation: Gender Neutral Language
    The use of language is a very powerful tool. Residents come from a variety of different backgrounds and experiences. Many may have experienced discrimination or hardshipsthroughout their lives. As a result, they may be sensitive to nuances in speaking or writing. Regardless of a resident’s experiences, respect and dignity is a cornerstone of the rights residents are entitled to in facilities. An important way of respecting residents is how they are spoken to during conversation. Another piece of respect includes how language is used within documentation. It is important to use gender neutral language in documentation. For instance, a male resident might be offended if an assessment states“resident was a male nurse”. Instead, the assessment should simply indicate resident was a nurse.

  • Objective Documentation: Observations
    Staff observe residents every day. Documenting those observations is a piece of accurate documentation that when done well provides understanding of that resident’s functioning and needs. However, staff should use care to only document observations. Stating “resident was angry today” is an interpretation of a resident’s behavior. That resident could have been angry, or he or she might have been tired and the staff interpreted expressions and behaviors as anger. Unless the resident told staff he or she was angry, the staff can more accurately document by using words such as “seemed” “presented” or “appeared”. Documentation of observations should be documentation of what staff observed, not the staff’s opinion of what was observed.

  • Objective Documentation: Opinions
    Opinions need to be clearly noted as opinions and not statements of fact. Staff should avoid opinions in documentation unless it is necessary. When it is necessary, staff could write "writer believes..." in order to show it is the staff member’s opinion. Staff should also take care to avoid writing about conditions that are undiagnosed. A staff member should refrain from such statements as “resident is alcoholic” when there is no documentation of a diagnosis of alcohol use.

  • Objective Documentation: Person Centered and Non-Blaming
    As previously outlined in Gender Neutral Language, language can be very powerful. The way a staff member writes about a resident’s situation can show respect and empathy.For instance, the example above of "resident is alcoholic" could be rephrased to "resident has experienced difficulty with alcohol use in the past." Although both statements may mean the same thing, the perspective of that resident as a person is vastly different. In the second phrase, the resident is a person who is not defined by his or her struggles with alcohol. In the first phrase, the writer is identifying the resident as an alcoholic, which is labeling that resident negatively. Other examples include "resident with a diagnosis of schizophrenia" versus "schizophrenic resident" and "resident uses a wheelchair" versus "wheelchair-bound resident." Using "resident" or resident's name first is a reminder to treat residents as people first and their diagnosis or condition second.

  • Objective Documentation: Quoting Others
    Sometimes staff can most effectively illustrate a situation by quoting an individual, whether that person is another staff member, resident, or family member. When doingso, staff need to write exactly what the person said and use quotation marks.

Documentation is an effective use of staff time that allows for improved understanding of a resident’s needs and care. Staff can show how a resident’s needs are being met and show respect for a resident’s experiences through careful and accurate documentation. With time and practice, respectful and accurate documentation can be achieved.  Documentation enhances residents’ lives by providing staff a tool for understanding that resident’s needs.

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